Jasmine Carpenter is a Mental Health Clinical Pharmacy Specialist; Danielle LaPrad and Yewande Dayo are Pharmacy Practice Residents; and Shannon DeGrote is a Clinical Pharmacy Specialist, all at the Washington DC VA Medical Center. Kasraie Williamson is a Pharmacy Resident at Memorial Regional Hospital in Hollywood, Florida. Correspondence: Jasmine Carpenter (jasmine.carpenter@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Gabapentin, baclofen, and ondansetron are also options for those with liver disease. Baclofen in particular has been studied in those with advanced liver disease, and it was found to be safe and effective.88,89
Comorbid Renal Disease
Naltrexone is an option for patients with mild renal impairment. Naltrexone and its major metabolite, 6-ß-naltrexol, are renally excreted; however, urinary excretion of unchanged naltrexone accounts for < 2% of the oral dose.19 Even with its low potential for accumulation, HCPs should carefully monitor for AEs in patients with moderate-to-severe renal impairment. Disulfiram is another pharmacotherapy option, since it is mostly metabolized by the liver.
Gabapentin, baclofen, and ondansetron are also possible options; however, their doses should be renally adjusted. Overall, there are limited studies on the use of these medications treating AUD in patients with renal impairment.
Pregnancy
Alcohol consumption during pregnancy can result in a wide range of birth defects to the unborn fetus. Due to the negative effects of alcohol consumption on the fetus, pregnant females should be referred to a professional alcohol treatment program. Although AUD pharmacotherapy may be considered in pregnant females, there have been no human studies that have examined the efficacy and safety in this patient population. All evidence comes from animal studies, case reports, and case series.90
Naltrexone is the most widely used medication for AUD in pregnancy. It is considered pregnancy category C and 1 study in particular did not detect any gross abnormalities in fetal development in pregnancy.19, 90 Disulfiram, acamprosate, and topiramate have all been shown to cause harm to either animal or human fetuses and are generally not recommended.36,44,63 Similar to naltrexone, gabapentin and baclofen are also pregnancy category C.69,77 Ondansetron is pregnancy category B, but it should still be used with caution since its use in pregnancy for the treatment of AUD has not been studied.77,90
Psychosocial Interventions
It is recommended that AUD pharmacotherapy be used in conjunction with a psychosocial intervention, such as CBT or medical management. Many of the studies evaluating the efficacy of AUD pharmacotherapy combined psychosocial interventions with medications. The literature suggests that when combined with CBT or medical management therapy, pharmacotherapy used for AUD results in better alcohol consumption outcomes.31,91 It has also been suggested that psychosocial interventions may improve patient adherence to AUD pharmacotherapy.25
Barriers
Inadequate HCP training on the use of AUD pharmacotherapy has been found to be a major barrier to the utilization of AUD pharmacotherapy, along with a lack of confidence in the effectiveness of these medications.18 Increasing HCP education on the use and benefits of these agents may increase the overall confidence of HCPs in prescribing pharmacotherapy for the treatment of AUD, especially in the primary care setting. One aspect that has been found to improve education and the prescribing of pharmacotherapy for AUD within the Veterans Health Administration has been the use of academic detailing programs.92 Academic detailing is a multifaceted educational outreach program that is used to assist with HCP education. Additionally, clinical pharmacists can be consulted to help develop a safe and effective AUD pharmacotherapy treatment regimen.
